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CASES MATERIA MEDICA GENERAL ARTICLES ABSTRACT MISCELLANEOUS Q & A

2nd NJH CME--Mumbai, July 96

The second in the series of CME sponsored by NJH was held at the Hinduja Hospital on 28th July 1996.

Dr Shroff and his colleagues gave practical and informative account of imaging techniques, corroborating it with X-ray films and slides.

  1. Plain X Ray Abdomen--should be in standing position. The reasons for advising a plain X-ray abdomen are-.
    1. Acute pain due to perforation (will show gas under diaphragm).
    2. To see calculi.

    Exception is a Gall bladder calculus which may not be seen due to the presence of cholesterol. In such instances an ultrasound will clinch the diagnosis.

    For an abdominal X-ray give 2 tablets of Dulcolax and a light diet the night before. For an acute abdomen, no preparation is necessary.

  2. X-Ray Spine:
    A two day preparation is recommended before the investigation. X-ray spine is recommended in case of -.
    1. Pain and tenderness in the spine (Kochs spine).
    2. Any deformity.
    3. Dermal sinus,.
    4. Trauma,.
    5. Fracture.
    6. Chronic backache.
    7. Metastasis--ask for AP lateral oblique views to rule out any changes.

    X-rays showing involvement of the pedicles of the vertebrae in metastasis and intervertebral discs in fungal, HIV and Kochs infection were shown.

    Always ask for an X-ray in a patient complaining of weakness of limbs with bowel and bladder involvement. It could be a disc prolapse. For low back pain of females advise an oblique LS film.

    A rare X-ray of a Scalloping defect of the vertebra was shown of a person who came in with an acute abdomen. He was diagnosed as an aortic aneurysm.

  3. X-Rays of Skeletal System:

    It involves X-ray films of skull, pelvis, upper and lower limbs, chest and spine.

    If one wants to see the extent of the disease in multiple bones, a whole body bone scan (Nuclear) is recommended. Nuclear scans are done to reduce radiation effects.

    A diagnostic film for hyper-parathyroidism, shows subperiosteal reabsorption in the metaphalyngeal joints.

    Juvenile Rheumatoid Arthritis, will show bilaterally symmetrical carpal osteoporosis and fusion with the chest X-ray showing upper limb fibrosis and subluxation in cervical spine. always follow local X-rays of parts involved with an X-ray spine.

    In Scleroderma, a soft tissue calcification is seen with bilateral basal fibrosis.
    In cases of trauma, clinical evidence is the most important criterion with an X-ray.
    In osteomyelitis, medullary dislocation in the soft tissue and swelling is seen.
    Avascular necrosis can be picked up on a Nuclear scan.
    Skeletal X-rays have an important role to play in cases of trauma, neoplasm, spread of disease, osteomyelitis and chronic dysplasias.
    Intravenous Urogram is recommended in painless haematuria especially in young adult (Kochs), colic, repeated urinary infections, young hypertensive (renal), narrowing of ureters etc.
    For vesico--urinary reflux a micturating cystogram is taken.
    Myelography is taken for unexplained backache with diffused involvement of intervertebral disc pathology. Since this is a dynamic test it is taken in different positions.

  4. Barium Studies:
    It involves Barium swallow, Barium upper GI, Barium follow through, small bowel enema and large bowel enema.
    1. Barium upper GI, for gastric outlet obstruction and ulcers.
    2. Barium Follow through, for right iliac fossa tenderness (Ileo caecal Kochs).
    3. Small bowel enema, for fistula and tuberculosis.
    4. Large bowel enema, for bleeding PR or any growth in the large bowel.

    Always ask for a Double contrast enema in mucosal diseases and tumours.
    The diagnosis of Ulcerative Colitis can be clinched by seeing the continuity of granularities of the mucosal walls.
    Adenocarcinoma is characteristically seen as an apple core appearance in a Barium X-ray. There is also a history of loss of weight and bleeding PR.
    An appearance of spiking and coins stacked above each other is characteristic of Lymphomas.

  5. Endoscopy: has replaced upper GI Barium study, since an endoscope can also take a biopsy and is more patient friendly.

  6. Ultrasound:
    High resolution probes have made ultrasound a method of choice. Ultrasonography with Doppler picks up signals from the flowing blood too.

    Abdominal scanning can pick up liver changes like polycystitis, abscess, calculi and lumps.

    A highly echogenic area on USG means a resolving abscess or fibrosis. An anechoic area means presence of fluid and hypoechoic area means a solid area.

    For gall bladder visualisation on USG means a resolving abscess or fibrosis. An anechoic area means presence of fluid and hypoechoic area means a solid area.

    Even for Pancreas the patient has to be fasting with fluid overloading.

    A calculus of more than 1 cm in the renal region can be seen only in the upper one third and lower one third of USG as a shadow.

    USG is recommended for small renal cortical lesions with haematuria, infections, to know the size of kidneys and chronic scarring.

    USG has entered the fields of Thyroid testing and Ophthalmic areas.

    Transvaginal USG is very accurate since the probe is right down into the organs.

  7. Mammography:

    In breast cancer, mammography can detect a tumour as small as 5mm by 5mm.

  8. CT Scan : Brain
    Indicated in Accident, Epilepsy; Tumours and neurological defects. No changes may be seen on CT scan for the first 12-24 hours of paralytic stroke.

    For the abdomen--one can ask for either an USG or a CT or MRI to see a focal lesion--haemangioma or renal cell carcinoma.

    For the Pelvis--USG and MRI.
    MRI is contraindicated in persons with pacemakers or any metallic foreign body.

    Transfontannelle USG is done for premature babies and neonates.

  9. HRCT--High resolution CT scan may be necessary in Interstitial Lung disease and Bronchiectasis and for pulmonary tuberculosis not seen on a plain X-ray chest.

  10. MRI : Magnetic Resonance Imaging

    It is done for degenerative spinal diseases, tumours and marrow abnormality. It is important to visualize soft tissue involvement eg Ligament. In CT of the lung specially ask for contrast to see mediastinal structure.

    Some of the simple truths about advanced techniques modern investigation made a deep impression on the participants and were well appreciated.

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